The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?
Attempt to deescalate the client.
Continue to observe the client for increased agitation.
Offer medications to help the client control behavior.
Ensure safety in the environment for the client and others.
The Correct Answer is D
A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Confusion is a common side effect following ECT. It is usually temporary and gradually resolves.
B) Incorrect. Long-term memory impairment is a potential side effect of ECT, but it is not immediate and is more of a concern with repeated sessions.
C) Incorrect. Feeling full of energy would not be an expected immediate side effect of ECT.
D) Incorrect. Numbness and tingling in the extremities are not typically associated with ECT.
Correct Answer is C
Explanation
A) Incorrect. Placing metal utensils on the client's meal tray may pose a safety risk, especially considering the recent suicide attempt.
B) Incorrect. Assigning the client to a private room may be beneficial for privacy, but the more immediate concern is ensuring the safety of the client by inspecting personal belongings.
C) Correct. Inspecting the client's personal belongings is crucial to remove any potentially harmful items that the client may use to harm themselves.
D) Incorrect. Tucking bedcovers over the client's hands and arms is not a specific intervention related to the recent suicide attempt.
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